Application for Permit to Install Underground Storage Tanks (Petroleum or Hazardous Substances) 1. Owner Information 2. Installation Site Information

Transcription

1 Papillion/La Vista Fire Marshal s Office Fuels Division FLST Section 146 rth Adams Street Papillion, NE (402) Application for Permit to Install Underground Storage Tanks (Petroleum or Hazardous Substances) Today s Date: Proposed Installation Date: 1. Owner Information 2. Installation Site Information Owner/Operator Site Name Mailing Address Street Address (or directions, if rural) City State Zip Code - City Zip Code - County Type of Installation: Tank(s) Piping Only Replacement ( 10% or more or 10 feet) Adding new piping to existing Complete all sections. 3. Tank Registration Did facility previously have underground storage tanks? Are tank registered with the State Fire Marshal? Indicate SFM Facility ID # Contact State Fire Marshal immediately. 4. Type of Facility Marketing (including Plants) n-marketing Government 5. Licensed Installation Contractor 6. Certified Individual

2 Company Name License # Individual Name Mailing Address Expiration Date Certification # Expiration Date City State ZIP Address: Address: 1 FLST 18 (rev 8/10) 7. Tank Information Tank Number # # # # # # Tank Type (erally Regulated or Heating Oil) Tank Capacity (Gallons) Substance Stored in Tank UL, Pr, E-10, E-85, E-95, #1D, #2D, #1, #2, K, WO, NO, DD (Dyed Diesel i.e., #2 DD) (Specify) Steel with Cathodic Specify Brand: Protection Check appropriate boxes: Jacketed Composite (ACT 100) Vinyl Is the Tank or? (Specify) te: tanks must be recertified by the manufacturer and a letter of recertification for all used tanks must accompany this permit application. Will the tank be used for enser or Storage? Is the tank connected to a stationary combustion engine (such as a generator, water pump, etc.?) Installation Backfill PEI RP 100 API 1615 Anchoring Manufacturer s Instructions Specify Backfill Material (specify grade) (If, attach current sieve analysis) Will an Alternate Backfill be used? (If yes, attach Alternate Backfill approval letter) Deadmen Overburden Both ne

3 Type of Secondary Containment Double Walled Excavation Liner Release Detection: Tanks Ground Water Monitoring Interstitial Monitoring(required) Tightness Testing Daily Inventory Control Brand/Model/Test Automatic Tank Gauging Manual Tank Gauging (SIR) Brand/Model/Test Soil Vapor Monitoring Corrosion Protection: Tanks Internal Internal Lining ne Unknown Spill Prevention Overfill Prevention 2 FLST 18 (rev 8/10) External Impressed Current Cathodic Protection Galvanic/Sacrificial Cathodic Protection Fiberglass/Epoxy Resin Clad ne (specify) Spill Containment Basin (specify) High Level Alarm Drop Tube Shut-Off (specify) 8. Description of Project and General Site Plan (If you need more space attach separate sheets.) Scope of Work (describe the extent of planned activities): If new or replacement piping, specify associated tank #s General Site Plan showing: Buildings on property Approximate location of tanks and piping Distances from tanks and piping to property lines/building Location of dispensers

4 NORTH 3 FLST 18 (rev 8/10) Piping System 9. Piping Piping Material Brand Steel with CP Flexible Plastic Corrosion Protection for Piping Release Detection for Piping (mark all that apply) Impressed Current Cathodic Protection Ground Water Monitoring Galvanic/Sacrificial Cathodic Protection Interstitial Monitoring (required) ne (made of non-corrodible materials) Electronic Leak Detectors (specify) Tightness Testing-Every 3 Yrs (Conventional Suction) Soil Vapor Monitoring Manual Leak Detectors Tightness Testing Annual (Pressurized) ne (Safe Suction) (SIR) Pressurized Conventional Suction Safe Suction If a pressurized system, will shear valve be rigidly anchored to dispenser island in accordance with manufacturer s installation instructions? Type of Secondary Containment Double Walled Excavation Liner Does the project include installation of motor fuel dispenser system? If yes, see Title 159, Chapter 4 Section B for under dispenser spill containment requirement. Distance from tank(s) to nearest property line (feet) Distance from tank(s) to nearest structure (feet) Depth to groundwater (feet) 10. General Information

5 Will an Electrical Permit be obtained? N/A Will dispensers use a card-trol or key-trol system? Is facility unattended at any time (day or night)? Does building have plastic water supply lines? Will One-Call procedure be followed? A fee of fiy dollars ($50) per tank or piping must be submitted with this application. Application will be approved or denied within ten (10) working days aer receipt of permit application and fee. Payment must be made by check or money order. Cash will not be accepted. All tanks must be installed in accordance with Title 159, State Fire Marshal Underground Storage Tank Rules and Regulations. tank or piping shall be covered before inspection by State Fire Marshal personnel. Inspection requests shall be made at least 72 hours prior to pre-installation to assure inspector availability. Inspections will be scheduled in the order requests are received. As built drawings, all tightness test results, proof of private insurance (if required) and the proper notification form shall be on site and available for the inspector before the tanks / piping are placed into service. Application Submitted By: (print name) (signature) If you would like this permit to be returned to you via , indicate address here: te: Incomplete or missing information may cause this application to be rejected and returned for corrections. If you have any questions about this form, call (402) FLST 18 (rev 8/10)